v2017.11.30

(For Office Use Only) / Material Transfer Agreement No. : / Date Received :

WAYNE STATE UNIVERSITY

Outgoing Material Transfer Agreement Questionnaire

This is an internal WSU document and should not be forwarded to the Recipient.

  1. Provider Scientist (name, title, address and email):
  1. Recipient Institution/Company (name and address):
  1. Recipient Scientist (name, title, address and email):
  1. Recipient MTA contact person (name, address and email):
  1. Name and description of the material(s), including data and/or software, to be transferred:

[Spell out any acronyms.]

  1. Quantity of material (please include units):
  1. List the transmittal fee that you will charge the recipient as reimbursement for preparation and distribution costs, if applicable:
  2. Do you need to charge the recipient any additional payments/fees? If so, please explain:
  1. Provide the desired termination date, if applicable (i.e. Is there a time limit for how long the recipient may use the material? e.g. months, years, when research completed, etc.):
  1. Will you be providing any confidential information (data, manuscript drafts, etc.) along with the transfer of materials?

NOTE: If so, please mark such documents as “CONFIDENTIAL” prior to shipping.

  1. If transferring human materials and/or human data:
  2. Will you be providing personally identifiable patient information? If so, please describe:
  3. If not providing personally identifiable patient information: Please describe the information:
  4. Will you be providing any information that could be used to identify an individual at a later time (e.g. a unique identification code)?
  5. Provide the WSU IRB protocol name and number under which the materials and/or data were originally obtained, if applicable:
  6. Please attach copies of any related IRB approval documents and patient consent forms.
  1. Are the materials genetically modified organisms? If so, please describe the gene or allele mutation that makes the organism unique:
  1. Were the materials modified, infected, and/or injected with a known pathogen, virus and/or bacteria for any reason? If so, please explain:
  1. Do you have any reason to believe that the material is potentially subject to any export control restrictions? If so, please explain:
  1. Purpose of transfer:
  2. Are you collaborating with the recipient for this project? If so, briefly describe the collaboration:
  3. If not collaborating: Is the recipient performing the research as a service to you?
  4. If not collaborating: Are you providing the materials to recipient as a service to recipient?
  5. If applicable, please attach copies of any related collaboration agreements, subcontractor agreements, service agreements, purchase orders, quotes or fee schedules.
  1. Permitted use of materials:
  2. What research/experiments etc. will the recipient scientist be conducting with the materials?
  3. Should there be any limitations on the use of the materials and/or research results? If so, please describe:
  4. Is the recipient allowed to modify the materials?
  5. Should the materials be returned or disposed of after use?
  6. What new material(s) and/or data, if any, will you receive back from the recipient?

[Examples: analysis results, DNA sequencing, etc.]

  1. By transferring the materials, will you substantially affect your (or other WSU investigators’) ability to complete additional research projects in the future?

[Example: WSU’s supply of the materials will be depleted due to transfer]

  1. Was the material developed with the use of any outside funding sources?
  2. If so, please list all granting sources and numbers:
  3. If applicable, please attach copies of any related funding/grant award documents.
  1. Is the material publicly available from another source (e.g. a repository or catalog)? If so, please provide the name of the source:
  1. Was the material obtained from a third party or developed elsewhere (e.g. by a collaborator or even by you elsewhere)? If so, please provide the name of the source/third party:
  1. Was the material developed with the use of any third-party materials? If so, please explain:
  2. Have you modified the third-party materials in any way? If so, please explain:
  3. If applicable, please attach copies of any related transfer agreement or purchase documents.
  1. Is this material related to an invention previously developed and disclosed (or to be disclosed) to WSU?
  2. If so, please describe (provide the WSU Technology ID number, if known):
  1. Based on what you know right now, do you think the transfer of the materials will directly lead to any commercial use? Why or why not?
  1. Is there any other information that will be important for us to know?

Signature of WSU (Provider) Scientist / Date

Please email the completed Outgoing MTA Questionnaire to Page 1 of 2